Flexi Blue pffs - Idaho Health Insurance Blue (PffS) ... sponsor. this benefit information provided herein is a brief summary, but not a comprehensive description of available

H5862 001 CS 10006 (09/09)

You think about cost-effective healthcare.

We think about providing coverage that fits your needs.

Flexi Blue pffs 2010 Summary of Benefits

Serving the State of Idaho

FLEXI BLUE PFFS 1 SummarY of BenefitS

General Disclaimersflexi Blue (PffS) is a medicare advantage organization with a medicare contract and is a medicare approved Part D ■■

sponsor.

this benefit information provided herein is a brief summary, but not a comprehensive description of available ■■

benefits. additional information about benefits is available to assist you in making a decision about your coverage. this is an advertisement; call Customer Service for more information.

a medicare advantage Private fee-for-Service plan works differently than a medicare supplement plan. Your doctor ■■

or hospital can continue to treat you if it agrees to accept our terms and conditions of payment, and thus may choose not to treat you, with the exception of emergencies. if your doctor or hospital does not agree to accept our payment terms and conditions, they may choose not to provide healthcare services to you, except in emergencies. Providers can find the plan’s terms and conditions on our Web site at: www.bcidaho.com/PFFSterms

medicare beneficiaries may enroll in flexi Blue (PffS) through the Centers for medicare and medicaid Services ■■

online enrollment Center, located at www.medicare.gov. for more information about online enrollment, contact Customer Service at the number below.

You must continue to pay your medicare Part B premium if you choose a medicare advantage plan. Switching your ■■

Part C method of payment (direct billing or premium withholding) can take up to three months. You are responsible for you Part C premium payment during this transition period.

Quantity limits may apply for mail order prescriptions. Call Customer Service for information on mail order ■■

prescription drug service.

if you enroll in flexi Blue (PffS) or any ma coordinated care (Hmo, PPo or PffS) plan, you will be automatically ■■

disenrolled from the coordinated care (Hmo, PPo or PffS) plan if you enroll in a stand-alone prescription drug plan.

Some covered services or medications may require prior authorization.■■

People with limited incomes may qualify for extra Help to pay for their prescription drug costs. if eligible, medicare ■■

could pay for seventy-five percent of drug costs including monthly prescription drug premiums, annual deductibles, and coinsurance. additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. many people are eligible for these savings and don’t even know it. for more information about this extra Help, contact your local Social Security office or call, 1-800-meDiCare (1-800-633-4227), 24 hours per day, 7 days per week. ttY users should call 1-877-486-2048.

for full information on flexi Blue (PffS) contact Customer Service at 1-888-494-2583 or ■■

tDD/ttY 1-800-377-1363 for the hearing impaired. We are available from 8 a.m. to 8 p.m. seven days a week.


thank you for your interest in flexi Blue (PffS). our plan is offered by BLue CroSS of iDaHo HeaLtH SerViCeS, inC./Blue Cross of idaho, a medicare advantage Private fee-for-Service organization. this Summary of Benefits tells you some features of our plan. it doesn’t list every service that we cover or list every limitation or exclusion. to get a complete list of our benefits, please call flexi Blue (PffS) and ask for the “evidence of Coverage”.

YOU HAVE CHOICES IN YOUR HEALTHCARE

as a medicare beneficiary, you can choose from different medicare options. one option is the original (fee-for-service) medicare plan. another option is a medicare advantage Private fee-for-Service plan, like flexi Blue (PffS). You may have other options too. You make the choice. no matter what you decide, you are still in the medicare program.

You may join or leave a plan only at certain times. Please call flexi Blue (PffS) at the telephone number listed at the end of this introduction or 1-800-meDiCare (1-800-633-4227) for more information. ttY/tDD users should call 1-877-486-2048. You can call this number 24 hours a day, 7 days a week.

HOW CAN I COMPARE MY OPTIONS?

You can compare flexi Blue (PffS) and the original medicare Plan using this Summary of Benefits. the charts in this booklet list some important health benefits. for each benefit, you can see what our plan covers and what the original medicare Plan covers.

our members receive all of the benefits that the original medicare Plan offers. We also offer more benefits, which may change from year to year.

WHERE IS FLEXI BLUE (PFFS) AVAILABLE?

the service area for this plan includes: ada, adams, Bannock, Bear Lake, Benewah, Bingham, Blaine, Boise, Bonner, Bonneville, Boundary, Butte, Camas, Canyon, Caribou, Cassia, Clark, Clearwater, Custer, elmore, franklin, fremont, Gem, Gooding, idaho, Jefferson, Jerome, Kootenai, Latah, Lemhi, Lewis, Lincoln, madison, minidoka, nez Perce, oneida, owyhee, Payette, Power, Shoshone, teton, twin falls, Valley, Washington Counties, iD. You must live in one of these areas to join the plan.

WHO IS ELIGIBLE TO JOIN FLEXI BLUE (PFFS)?

You can join flexi Blue (PffS) if you are entitled to medicare Part a and enrolled in medicare Part B and live in the service area. However, individuals with end Stage renal Disease are generally not eligible to enroll in flexi Blue (PffS) unless they are members of our organization and have been since their dialysis began.

CAN I CHOOSE MY DOCTORS?

a medicare advantage Private fee-for-Service plan works differently than a medicare supplement plan. Your doctor or hospital is not required to agree to accept the plan’s terms and conditions, and thus may choose not to treat you, with the exception of emergencies. if your doctor or hospital does not agree to accept our payment terms and conditions, they may choose not to provide healthcare services to you, except in emergencies.

DOES MY PLAN COVER MEDICARE PART B OR PART D DRUGS?

flexi Blue (PffS) does cover both medicare Part B prescription drugs and medicare Part D prescription drugs.

Section 1introduction to the Summary of Benefits report

for flexi Blue (PffS)January 1, 2010 – December 31, 2010

State of Idaho


WHERE CAN I GET MY PRESCRIPTIONS IF I JOIN THIS PLAN?

flexi Blue (PffS) has formed a network of pharmacies. You must use a network pharmacy to receive plan benefits. We may not pay for your prescriptions if you use an out-of-network pharmacy, except in certain cases. the pharmacies in our network can change at any time. You can ask for a pharmacy directory or visit us at bcidaho.com/ma_formulary. our customer service number is listed at the end of this introduction.

WHAT IS A PRESCRIPTION DRUG FORMULARY?

flexi Blue (PffS) uses a formulary. a formulary is a list of drugs covered by your plan to meet patient needs. We may periodically add, remove, or make changes to coverage limitations on certain drugs or change how much you pay for a drug. if we make any formulary change that limits our members’ ability to fill their prescriptions, we will notify the affected enrollees before the change is made. We will send a formulary to you and you can see our complete formulary on our Web site at bcidaho.com/ma_formulary.

if you are currently taking a drug that is not on our formulary or subject to additional requirements or limits, you may be able to get a temporary supply of the drug. You can contact us to request an exception or switch to an alternative drug listed on our formulary with your physician’s help. Call us to see if you can get a temporary supply of the drug or for more details about our drug transition policy.

HOW CAN I GET EXTRA HELP WITH MY PRESCRIPTION DRUG PLAN COSTS?

You may be able to get extra help to pay for your prescription drug premiums and costs. to see if you qualify for getting extra help, call: 1-800-meDiCare (1-800-633-4227). ttY/tDD users should call 1-877-486-2048, 24 hours a day/7 days a week; the Social Security administration at 1-800-772-1213 between 7 a.m. and 7 p.m., monday through friday. ttY/tDD users should call 1-800-325-0778; or your State medicaid office.

WHAT ARE MY PROTECTIONS IN THIS PLAN?

all medicare advantage Plans agree to stay in the program for a full year at a time. each year, the plans decide whether to continue for another year. even if a medicare advantage Plan leaves the program, you will not lose medicare coverage. if a plan decides not to continue, it must send you a letter at least 60 days before your coverage will end. the letter will explain your options for medicare coverage in your area.

as a member of flexi Blue (PffS), you have the right to request an organization determination, which includes the right to file an appeal if we deny coverage for an item or service, and the right to file a grievance. You have the right to request an organization determination if you want us to provide or pay for an item or service that you believe should be covered. if we deny coverage for your requested item or service, you have the right to appeal and ask us to review our decision. You may ask us for an expedited (fast) coverage determination or appeal if you believe that waiting for a decision could seriously put your life or health at risk, or affect your ability to regain maximum function. if your doctor makes or supports the expedited request, we must expedite our decision. finally, you have the right to file a grievance with us if you have any type of problem with us or one of our network providers that does not involve coverage for an item or service. if your problem involves quality of care, you also have the right to file a grievance with the Quality improvement organization (Qio) for your state, Qualis Health, 1-877-290-4346.

as a member of flexi Blue (PffS), you have the right to request a coverage determination, which includes the right to request an exception, the right to file an appeal if we deny coverage for a prescription drug, and the right to file a grievance. You have the right to request a coverage determination if you want us to cover a Part D drug that you believe should be covered. an exception is a type of coverage determination. You may ask us for an exception if you believe you need a drug that is not on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-


pocket cost. You can also ask for an exception to cost utilization rules, such as a limit on the quantity of a drug. if you think you need an exception, you should contact us before you try to fill your prescription at a pharmacy. Your doctor must provide a statement to support your exception request. if we deny coverage for your prescription drug(s), you have the right to appeal and ask us to review our decision. finally, you have the right to file a grievance if you have any type of problem with us or one of our network pharmacies that does not involve coverage for a prescription drug. if your problem involves quality of care, you also have the right to file a grievance with the Quality improvement organization (Qio) for your state, Qualis Health, 1-877-290-4346.

WHAT IS A MEDICATION THERAPY MANAGEMENT (MTM) PROGRAM?

a medication therapy management (mtm) Program is a free service we may offer. You may be invited to participate in a program designed for your specific health and pharmacy needs. You may decide not to participate but it is recommended that you take full advantage of this covered service if you are selected. Contact flexi Blue (PffS) for more details.

WHAT TYPES OF DRUGS MAY BE COVERED UNDER MEDICARE PART B?

Some outpatient prescription drugs may be covered under medicare Part B. these may include, but are not limited to, the following types of drugs. Contact flexi Blue (PffS) for more details.

Some Antigens:■■ if they are prepared by a doctor and administered by a properly instructed person (who could be the patient) under doctor supervision.

Osteoporosis Drugs:■■ injectable drugs for osteoporosis for certain women with medicare.

Erythropoietin (Epoetin Alfa or Epogen■■ ®): By injection if you have end-stage renal disease (permanent kidney failure requiring either dialysis or transplantation) and need this drug to treat anemia.

Hemophilia Clotting Factors:■■ Self-administered clotting factors if you have hemophilia.

Injectable Drugs:■■ most injectable drugs administered incident to a physician’s service.

Immunosuppressive Drugs:■■ immunosuppressive drug therapy for transplant patients if the transplant was paid for by medicare, or paid by a private insurance that paid as a primary payer to your medicare Part a coverage, in a medicare-certified facility.

Some Oral Cancer Drugs:■■ if the same drug is available in injectable form.

Oral Anti-Nausea Drugs:■■ if you are part of an anti-cancer chemotherapeutic regimen.

Inhalation and Infusion Drugs■■ provided through Dme.

PLAN RATINGSthe medicare program rates how well plans perform in different categories (for example, detecting and preventing illness, ratings from patients and customer service). if you have access to the web, you may use the web tools on www.medicare.gov and select “Compare medicare Prescription Drug Plans” or “Compare Health Plans and medigap Policies in Your area” to compare the plan ratings for medicare plans in your area. You can also call us directly at 1-888-494-2583 to obtain a copy of the plan ratings for this plan. ttY users call 1-800-377-1363.


PLEASE CALL BLUE CROSS OF IDAHO FOR MORE INFORMATION ABOUT FLEXI BLUE (PFFS).

Visit us at www.bcidaho.com/medicare or, call us:

CUSTOMER SERVICE HOURS: Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8:00 a.m. - 8:00 p.m. Mountain

CURRENT MEMBERS should call toll-free 1-866-588-6167 for questions related to the Medicare Advantage Program.

TTY/TDD 800-377-1363.

PROSPECTIVE MEMBERS should call toll-free 1-888-492-2583 for questions related to the Medicare Advantage Program.

TTY/TDD 800-377-1363.

CURRENT MEMBERS should call locally 208-395-8200 for questions related to the Medicare Advantage Program.

TTY/TDD 800-377-1363.

PROSPECTIVE MEMBERS should call locally 208-387-6673 for questions related to the Medicare Advantage Program.

TTY/TDD 800-377-1363.

FOR MORE INFORMATION ABOUT MEDICARE, PLEASE CALL MEDICARE AT 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You can call 24 hours a day, 7 days a week.

Or, visit www.medicare.gov on the web.

If you have special needs, this document may be available in other formats.


BENEFIT CATEGORY ORIGINAl MEdICARE FlExI BluE (PFFS)

Important Information1. Premium AND Other imPOrtANt iNfOrmAtiON In 2009 the monthly Part B Premium was $96.40 and

will change for 2010 and the yearly deductible amount was $135 and will change for 2010.

If a doctor or supplier does not accept assignment, their costs are often higher, which means you pay more.

Most people will pay the standard monthly Part B premium. However, starting January 1, 2010, some people will pay a higher premium because of their yearly income (For 2009 this amount was $85,000 for singles, $170,000 for married couples. This amount will change for 2010.) For more information about Part B premiums based on income, call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

General $27 monthly plan premium in addition to your monthly Medicare Part B premium.

This plan does not allow providers to balance bill (charging more than your cost share amount)

$3,000 out-of-pocket limit.

This limit includes only Medicare-covered services.

2. DOctOr AND hOsPitAl chOice (for more information, see emergency, #15 and urgently needed Care, #16.)

You may go to any doctor, specialist or hospital that accepts Medicare.

You may go to any doctor, specialist, or hospital that accepts the plan’s terms and conditions of payment.

Summary of Benefits Report for ContraCt H5862, Plan 001



Summary of Benefits Inpatient Care3. iNPAtieNt hOsPitAl cAre

(includes Substance abuse and rehabilitation Services.)

In 2009 the amounts for each benefit period were: Days 1-60: $1,068 deductible Days 61-90: $267 per day Days 91-150: $534 per lifetime reserve day These amounts will change for 2010.

Please Call 1-800-MEDICARE (1-800-633-4227) for information about lifetime reserve days.

Lifetime reserve days can only be used once.

A “benefit period” starts the day you go into a hospital or skilled nursing facility. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have.

General You may go to any doctor, specialist, or hospital that accepts the plan’s terms and conditions of payment except in emergencies.

For Medicare-covered hospital stays: Days 1-10: $150 copay per day Days 11-90: $0 copay per day

$0 copay for each additional hospital day.

No limit to the number of days covered by the plan each benefit period.

4. iNPAtieNt meNtAl heAlthcAre Same deductible and copay as inpatient hospital care (see “Inpatient Hospital Care” above).

190 day lifetime limit in a Psychiatric Hospital.

For Medicare-covered hospital stays: Days 1-10: $150 copay per day Days 11-90: $0 copay per day

You get up to 190 days in a Psychiatric Hospital in a lifetime.



5. skilleD NursiNg fAcility (sNf)(In a Medicare–certified skilled nursing facility.)

In 2009 the amounts for each benefit period after at least a 3-day covered hospital stay were: Days 1-20: $0 per day Days 21-100: $133.50 per day These amounts will change for 2010.

100 days for each benefit period.

A “benefit period” starts the day you go into a hospital or SNF. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have.

For SNF stays: Days 1-19: $0 copay per day Days 20-100: $128 copay per day

Plan covers up to 100 days each benefit period

No prior hospital stay is required.

6. hOme heAlthcAre(Includes medically necessary intermittent skilled nursing care, home health aide services and rehabilitation services, etc.)

$0 copay. $0 copay for Medicare-covered home health visits.

7. hOsPice You pay part of the cost for outpatient drugs and inpatient respite care.

You must get care from a Medicare-certified hospice.

General You must get care from a Medicare-certified hospice.



Outpatient Care8. DOctOr Office Visits 20% coinsurance. General

You may go to any doctor, specialist, or hospital that accepts the plan’s terms and conditions of payment.

See “Physical Exams,” for more information.

$30 copay for each primary care doctor visit for Medicare-covered benefits.

$30 copay for each specialist visit for Medicare-covered benefits.

9. chirOPrActic serVices Routine care not covered.

20% coinsurance for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers.

$30 copay for Medicare-covered visits.

Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers.

10. PODiAtry serVices Routine care not covered.

20% coinsurance for medically necessary foot care, including care for medical conditions affecting the lower limbs.

$30 copay for each Medicare-covered visit.

Medicare-covered podiatry benefits are for medically-necessary foot care.

11. OutPAtieNt meNtAl heAlthcAre 45% coinsurance for most outpatient mental health services.

$30 copay [or 20% of the cost] for each Medicare-covered individual or group therapy visit.

$30 copay for each Medicare-covered individual or group therapy visit with a psychiatrist.

12. OutPAtieNt substANce Abuse cAre 20% coinsurance. $30 copay [or 20% of the cost] Care for Medicare-covered individual or group visits.

13. OutPAtieNt serVices/surgery 20% coinsurance for the doctor.

20% of outpatient facility charges.

20% of the cost for each Medicare-covered ambulatory surgical center visit.

20% of the cost for each Medicare-covered outpatient hospital facility visit.



14. AmbulANce serVices (Medically necessary ambulance services.)

20% coinsurance. $150 copay for Medicare-covered ambulance benefits.

15. emergeNcy cAre (You may go to any emergency room if you

reasonably believe you need emergency care.)

20% coinsurance for the doctor.

20% of facility charge, or a set copay per emergency room visit.

You don’t have to pay the emergency room copay if you are admitted to the hospital for the same condition within 3 days of the emergency room visit.

NOT covered outside the U.S. except under limited circumstances.

General

$50 copay for Medicare-covered emergency room visits.

20% of the cost (up to $50) for Medicare-covered emergency room visits.

$25,000 limit for emergency services outside the U.S. every year.

If you are immediately admitted to the hospital, you pay $0 for the emergency room visit.

If you are admitted to the hospital within 3-day(s) for the same condition, you pay $0 for the emergency room visit.

16. urgeNtly NeeDeD cAre (this is not emergency care and in most cases, is out of the service area.)

20% coinsurance, or a set copay.

NOT covered outside the U.S. except under limited circumstances.

General Cost sharing is the same as Doctor Office Visit cost sharing.

17. OutPAtieNt rehAbilitAtiON serVices(occupational therapy, Physical therapy, Speech and language therapy)

20% coinsurance. $30 copay for Medicare-covered Occupational Therapy visits.

$30 copay for Medicare-covered Physical and/or Speech/Language Therapy visits.



Outpatient Medical Services and Supplies18. DurAble meDicAl equiPmeNt

(Includes wheelchairs, oxygen, etc.)20% coinsurance. 20% of the cost for Medicare-covered items.

19. PrOsthetic DeVices(Includes braces, artificial limbs and eyes, etc.)

20% coinsurance. 20% of the cost for Medicare-covered items.

20. DiAbetes self-mONitOriNg trAiNiNg, NutritiON therAPy, AND suPPlies(Includes coverage for glucose monitors, test strips, lancets, screening tests and self-management training.)

20% coinsurance.

Nutrition therapy is for people who have diabetes or kidney disease (but aren’t on dialysis or haven’t had a kidney transplant) when referred by a doctor. These services can be given by a registered dietitian or include a nutritional assessment and counseling to help you manage your diabetes or kidney disease.

$0 copay for Diabetes self-monitoring training.

$0 copay for Nutrition Therapy for Diabetes.

20% of the cost for Diabetes supplies.

Separate Office Visit cost sharing of $30 copay may apply.

21. DiAgNOstic tests, X-rAys, lAb serVices, AND rADiOlOgy serVices

20% coinsurance for diagnostic tests and x-rays.

$0 copay for Medicare-covered lab services.

Lab Services: Medicare covers medically necessary diagnostic lab services that are ordered by your treating doctor when they are provided by a Clinical Laboratory Improvement Amendments (CLIA) certified laboratory that participates in Medicare. Diagnostic lab services are done to help your doctor diagnose or rule out a suspected illness or condition. Medicare does not cover most routine screening tests, like checking your cholesterol.

$30 copay [or 20% of the cost] for Medicare-covered lab services.

$30 copay [or 20% of the cost] for Medicare-covered diagnostic procedures and tests.

$30 copay [or 20% of the cost] for Medicare-covered X-rays.

$30 copay [or 20% of the cost] for Medicare-covered diagnostic radiology services.

$30 copay [or 20% of the cost] for Medicare-covered therapeutic radiology services.



Preventive Services22. bONe mAss meAsuremeNt

(for people with Medicare who are at risk.)20% coinsurance.

Covered once every 24 months (more often if medically necessary) if you meet certain medical conditions.

$0 copay for Medicare-covered bone mass measurement.


23. cOlOrectAl screeNiNg eXAms (for people with Medicare age 50 and older.)

20% coinsurance.

Covered when you are high risk or when you are age 50 and older.

$0 copay for Medicare-covered colorectal screenings.


24. immuNizAtiONs(flu vaccine, Hepatitis B vaccine—for people with Medicare who are at risk, Pneumonia vaccine.)

$0 copay for Flu and Pneumonia vaccines.

20% coinsurance for Hepatitis B vaccine.

You may only need the Pneumonia vaccine once in your lifetime. Call your doctor for more information.

$0 copay for Flu and Pneumonia vaccines.

$0 copay for Hepatitis B vaccine.

25. mAmmOgrAms (ANNuAl screeNiNg)(for women with Medicare age 40 and older.)

20% coinsurance.

No referral needed.

Covered once a year for all women with Medicare age 40 and older. One baseline mammogram covered for women with Medicare between age 35 and 39.

$0 copay for Medicare-covered screening mammograms.




26. PAP smeArs AND PelVic eXAms(for women with Medicare.)

$0 copay for Pap smears.

Covered once every 2 years. Covered once a year for women with Medicare at high risk.

20% coinsurance for Pelvic Exams.

$0 copay for Medicare-covered pap smears and pelvic exams.


27. PrOstAte cANcer screeNiNg eXAms (for men with Medicare age 50 and older.)

20% coinsurance for the digital rectal exam.

$0 for the PSA test; 20% coinsurance for other related services.

Covered once a year for all men with Medicare over age 50.

$0 copay for Medicare-covered prostate cancer screening.


28. eND-stAge reNAl DiseAse 20% coinsurance for renal dialysis.

20% coinsurance for Nutritional Therapy for End-Stage Renal Disease.

Nutrition therapy is for people who have diabetes or kidney disease (but aren’t on dialysis or haven’t had a kidney transplant) when referred by a doctor. These services can be given by a registered dietitian or include a nutritional assessment and counseling to help you manage your diabetes or kidney disease.

20% of the cost for renal dialysis.

$0 copay for Nutrition Therapy for End-Stage Renal Disease.



29. PrescriPtiON Drugs Most drugs are not covered under Original Medicare. You can add prescription drug coverage to Original Medicare by joining a Medicare Prescription Drug Plan, or you can get all your Medicare coverage, including prescription drug coverage, by joining a Medicare Advantage Plan or a Medicare Cost Plan that offers prescription drugs.

Drugs covered under Medicare Part B

General 20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs.

Drugs Covered under Medicare Part D

General This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://www.bcidaho.com/ma_formulary on the Web.

Different out-of-pocket costs may apply for people who

- have limited incomes,

- live in long term care facilities, or

- have access to Indian/Tribal/Urban (Indian Health Service).

The plan offers national in-network prescription coverage. (i.e., this would include 50 states and DC). This means that you will pay the same amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan’s service area (for instance when you travel).

Total yearly drug costs are the total drug costs paid by both you and the plan. Some drugs have quantity limits.

Your provider must get prior authorization from Flexi Blue (PFFS) for certain drugs.

If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will pay the actual cost, not the higher cost-sharing amount.

If you request a formulary exception for a drug and Flexi Blue (PFFS) approves the exception, you will pay Tier 3 non-preferred brand cost sharing for that drug.

$0 deductible.



29. PrescriPtiON Drugs (cONt.) Initial Coverage

You pay the following until total yearly drug costs reach $2,830:

Retail Pharmacy

Tier 1 - Preferred Generic

- $5 copay for a one-month (30-day) supply of drugs in this tier

- $15 copay for a three-month (90-day) supply of drugs in this tier

Tier 2 - Preferred Brand



Tier 3 - Non-Preferred Brand



Tier 4 - Injectable Drugs

- 25% coinsurance for a one-month (30-day) supply of drugs in this tier

- 25% coinsurance for a three-month (90-day) supply of drugs in this tier

Tier 5 - Specialty Drugs





29. PrescriPtiON Drugs (cONt.) Long Term Care Pharmacy











Mail Order









29. PrescriPtiON Drugs (cONt.) Tier 3 - Non-Preferred Brand









Coverage Gap

After your total yearly drug costs reach $2,830, you pay 100% until your yearly out-of-pocket drug costs reach $4,550.

Catastrophic Coverage

After your yearly out-of-pocket drug costs reach $4,550, you pay the greater of:

- A $2.50 copay for generic (including brand drugs treated as generic) and a $6.30 copay for all other drugs, or

- 5% coinsurance.



29. PrescriPtiON Drugs (cONt.) Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan’s service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy’s full charge for the drug and submit documentation to receive reimbursement from Flexi Blue (PFFS).

Out-of-Network Initial Coverage

You will be reimbursed up to the full cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2,830:













29. PrescriPtiON Drugs (cONt.) Out-of-Network Coverage Gap

After your total yearly drug costs reach $2,830, you pay 100% of the pharmacy’s full charge for drugs purchased out-of-network until your yearly out-of-pocket drug costs reach $4,550. You will not be reimbursed by Flexi Blue (PFFS) for out-of-network purchases when you are in the coverage gap. However, you should still submit documentation to Flexi Blue (PFFS) so we can add the amounts you spent out-of-network to your total out-of-pocket costs for the year.

Out-of-Network Catastrophic Coverage

After your yearly out-of-pocket drug costs reach $4,550, you will be reimbursed for drugs purchased out-of-network up to the full cost of the drug minus the following:

- A $2.50 copay for generic (including brand drugs treated as generic) and a $6.30 copay for all other drugs, or

- 5% coinsurance.

30. DeNtAl serVices Preventive dental services (such as cleaning) not covered.

In general, preventive dental benefits (such as cleaning) not covered.

20% of the cost for Medicare-covered dental benefits.

31. heAriNg serVices Routine hearing exams and hearing aids not covered.

20% coinsurance for diagnostic hearing exams.

Hearing aids not covered.

- $30 copay for Medicare-covered diagnostic hearing exams

- $30 copay for up to 1 routine hearing test(s) every year



32. VisiON serVices 20% coinsurance for diagnosis and treatment of diseases and conditions of the eye.

Routine eye exams and glasses not covered.

Medicare pays for one pair of eyeglasses or contact lenses after cataract surgery.

Annual glaucoma screenings covered for people at risk.

Non-Medicare-covered eye exams and glasses not covered. - $30 copay for one pair of eyeglasses or contact lenses after cataract surgery.

- $30 copay for exams to diagnose and treat diseases and conditions of the eye.

33. PhysicAl eXAms 20% coinsurance for one exam within the first 12 months of your new Medicare Part B coverage.

When you get Medicare Part B, you can get a one time physical exam within the first 12 months of your new Part B coverage. The coverage does not include lab tests.

$30 copay for routine exams.

Limited to 1 exam(s) every year.

$30 copay for Medicare-covered benefits.

34. heAlth/WellNess eDucAtiON Smoking Cessation:

Covered if ordered by your doctor. Includes two counseling attempts within a 12-month period if you are diagnosed with a smoking-related illness or are taking medicine that may be affected by tobacco. Each counseling attempt includes up to four face-to-face visits. You pay coinsurance, and Part B deductible applies.

The plan covers the following health/wellness education benefits:

- Written health education materials, including Newsletters

- Other Wellness Benefits

$0 copay for each Medicare-covered smoking cessation counseling session.

n

it’s a ratio that most-accurately represents our dedication to unparalleled customer service and to you,

our number-one pr iority.n

one oneTO

An independent licensee of the blue cross and blue shield Association

Serving the State of Idaho

3000 east Pine avenue | meridian, idaho | 83642-5995Mailing Address: P.o. Box 8406 | Boise, idaho | 83707-1408

1-888-492-2583 | ttY 1-800-377-1363

medicare Advantage Plans | True Blue® HMO | Secure BlueSMPPO | Flexi BlueSMPFFS

Form No. 16-045 (09-09)H5862 001 CS 10006 (09/09)

Documents

Flexi Blue pffs - Idaho Health Insurance Blue (PffS) ... sponsor. this benefit information provided herein is a brief summary, but not a comprehensive description of available